Nursing Elites

1. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

• A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
• B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
• C. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
• D. Direct the client to occupational therapy to distract him from somatic complaints.

Correct answer: C

Rationale: The client is experiencing a dystonic reaction due to dopamine depletion, which is a known side effect of Risperidone. Dystonia presents as abnormal muscle contractions and postures. The immediate management for this side effect is the administration of an anticholinergic medication like Benztropine (Cogentin). Choice A is incorrect as thioridazine is not the recommended medication for dystonic reactions. Choice B is incorrect as a hot pack would not effectively address the underlying cause of the dystonic reaction. Choice D is incorrect as occupational therapy is not the appropriate intervention for managing acute dystonia.

2. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?

• A. Unless your sister has a medical education, ignore her comments.
• B. I can hear that your sister comments are over-whelming you.
• C. Do you think it’s possible that you might be a hypochondriac?
• D. Besides your sister’s comments, what in your life is troubling you?

Correct answer: B

Rationale: Acknowledging the impact of the sister's comments on the client helps validate the client's feelings and supports therapeutic dialogue.

3. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?

• A. Not sleeping for several days.
• B. Wishing to be with the deceased significant other.
• C. Lack of interest in usual activities.
• D. Eating very little.

Correct answer: A

Rationale: The most important client statement for the RN to explore in this scenario is the client not sleeping for several days. The lack of sleep is a critical indicator of possible severe depression or suicidal ideation that requires immediate attention. While expressing a wish to be with the deceased significant other, having a lack of interest in usual activities, and eating very little are concerning, the immediate focus should be on the client's severe sleep disturbance as it can pose an immediate risk to their well-being and safety.

4. A male client approaches the RN with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” The RN recognizes that the client is using which defense mechanism?

• A. Denial.
• B. Projection.
• C. Rationalization.
• D. Splitting.

Correct answer: B

Rationale: The correct answer is B: Projection. Projection involves attributing one's own unacceptable feelings or thoughts to others, as seen in the client’s accusations of his roommate’s behavior. In this scenario, the client is projecting his own anger and potential for violence onto his roommate. Choice A, Denial, involves refusing to acknowledge some aspect of reality, which is not evident in the scenario. Choice C, Rationalization, is a defense mechanism where logical reasons are given to justify behaviors that are actually based on unacceptable motives, which is not demonstrated by the client's behavior. Choice D, Splitting, is a defense mechanism where a person sees others as all good or all bad, not applicable in this case as the client is not portraying extreme views of his roommate.

5. The nurse is planning client teaching for a 35-year-old client with early alcoholic cirrhosis. Which self-care measure should the nurse emphasize for the client’s recovery?

• A. Support group meetings.
• B. Vitamin B and multivitamin supplements.
• C. Diet with adequate calories and protein.
• D. Alcohol abstinence.

Correct answer: D

Rationale: Alcohol abstinence is the most critical self-care measure for a client with early alcoholic cirrhosis. Continued alcohol consumption can lead to further liver damage and worsen the condition. Support group meetings may offer emotional support but do not address the root cause of the issue. While vitamin supplements and a nutritious diet are important for overall health, alcohol abstinence takes precedence in managing cirrhosis caused by alcohol consumption.

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